Household air pollution and pneumonia in Africa – will cleaner cookstoves make a difference?

Stephen Gordon heads the Department of Clinical Services at the Liverpool School of Tropical Medicine (LSTM), Liverpool, UK, and is an Honorary Consultant in General Medicine at the Royal Liverpool University Hospital and University Hospital Aintree. He combines Respiratory and General Medicine with research and teaching at LSTM.

Half the world’s population, including 700 million people in Africa, use biomass fuel from animal or plant material to provide energy for cooking, heating, and lighting. People who use biomass fuel and young children, particularly babies carried on the backs of their mothers while cooking, experience substantial smoke exposure due to both partial combustion of fuel and to poor ventilation methods. The newly formed BREATHE partnership (Biomass Reduction and Environmental Air Towards Health Effects), which is hosted and coordinated out of the Liverpool School of Tropical Medicine (LSTM), is increasing the much needed research capacity into this global health risk.

Smoke inhalation – household air pollution is similar to tobacco - is an established threat to health and has been associated with a range of adverse health effects including adverse pregnancy and neonatal outcomes, acute lower respiratory tract infections (causing 1 million deaths among the under 5s every year), chronic obstructive pulmonary disease, and lung cancer. During the past 10 years, our published data from Africa have shown that (a) biomass fuel smoke was associated with high levels of household air pollution, (b) symptoms and impaired lung function were associated with biomass fuel smoke exposure and poverty, and (c) household air pollution was associated with altered alveolar macrophage particulate load and function. In addition to direct adverse health effects, inefficient burning of biomass fuel is a contributor to adverse environmental and climate change effects by degradation of forests and greenhouse gas emissions and these factors are increasingly recognised as independent risks for adverse health outcomes.

Although some effective strategies for reducing smoke exposure exist (eg, ventilation, improved stoves, cleaner fuels, behaviour modification) and have been actively promoted for a decade by the Partnership for Clean Indoor Air, the best solutions remain out of reach for the majority due to economic factors. Further, there have been no randomised controlled trials exploring the effects of biomass smoke exposure reduction interventions on health outcomes in Africa. Only two trials have been carried out elsewhere in the world: one in Mexico and the other in Guatemala. Romieu et al compared a Patsari stove intervention with traditional open fire on respiratory and other symptoms and lung function in 552 women in Central Mexico. A reduction in symptoms and lung function decline was seen in those who used the new Patsari stove. The RESPIRE trial randomised 504 rural Mayan women in highland Guatemala to a Plancha stove intervention or open fire and assessed the impact on a range of respiratory health parameters. The Plancha stove reduced child and mother carbon monoxide exposures and chronic respiratory symptoms despite only a 50% reduction in indoor air pollution which left residual levels still well above WHO Air Quality Guidelines. Child pneumonia incidence was associated with smoke exposure and a reduction in severe pneumonia was seen with the stove intervention. We are aware of three current cookstove trials. One trial in Nepal is exploring the effects of a cookstove intervention on acute lower respiratory tract infection and low birthweight. A trial under development in Ghana will reduce household air pollution exposure and study early life outcomes. We have ourselves recently started the Cook Stoves and Pneumonia Study (CAPS) in Malawi.

It is of critical importance to make the most of the two trials that are planned and any other trials that will soon take place in Africa. The Global Alliance for Clean Cookstoves (GACC) was formed in 2010 and is committed to “foster the adoption of clean cook stoves and fuels in 100 million households by 2020” in order to “save lives, improve livelihoods, empower women, and combat climate change”. The GACC Health Working group, of which we are members, are very concerned by the need to harmonise protocols, exposure measurements, health effect measurements, and analyses in existing and future studies. The BREATHE Partnership has just been funded by the UK Medical Research Council in order to advance this agenda and to increase research capacity in Africa.

The strategic aim of the BREATHE-Africa Partnership is to develop and manage a coordinated portfolio of themed projects which link major well-resourced study sites and research teams focused on improving health among adults and children in Africa by reducing morbidity and mortality due to biomass fuel smoke exposure. We welcome new participants and discussion.

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